Introduction

Sexual assault is defined as sexual contact between individuals without appropriate legal consent. Rape is one form of sexual assault involving penetration, however slight, of the vaginal or anal opening. Though physical force may be used, sexual assault includes coercion into sexual contact by intimidation, threats, or fear. Local laws variably define the exact acts that constitute sexual contact and the specific populations unable to give legal consent. In general, those under the influence of drugs or alcohol, minors, and developmentally delayed individuals may be considered unable to give consent for sexual contact. [1]

All providers must conduct a compassionate, complete history and physical examination of any patient regardless of age, gender, or sexual orientation after sexual assault. The complex nexus between a provider caring for a patient and police requests for evidence must be addressed with the patient before collection. Each examination must be tailored to the specific circumstances reported by the patient rather than a one-protocol-fits-all approach. [2]

Function

Patients who are sexually assaulted may present directly to medical providers for treatment or present accompanied by law enforcement personnel. Medical professionals must provide compassionate and confidential treatment in a timely fashion. Psychosocial support begins with the first patient contact. All medical providers with subsequent contact need to use sensitivity and maintain patient confidentiality. Prior arrangements should be made with local sexual assault crisis centers and social work facilities to provide immediate support and assistance with the evaluation procedure.[3] A family member or friend may accompany a victim. In most cases, allow this person to stay with the victim in accordance with his or her wishes. Additionally, if a victim presents alone, medical providers should offer her the chance to call a companion and/or a crisis advocate to accompany him or her during the evaluation.

Providers must address and treat any life-threatening or limb-threatening physical injury and assess for suicidality. A minority of sexually assaulted patients require such immediate intervention, but in the rare case of coexistent severe trauma, providers should be careful to preserve evidence on the patient’s body if possible by using gloves and avoiding washing off areas that may have potential secretions. Some states mandate that providers contact law enforcement for patients reporting sexual assault. Providers must know local laws governing such reporting. Even when states mandate reporting, federal United States law permits all patients to undergo a forensic examination without charge. Patients undergoing forensic examinations are not required to discuss the event with the police.

If the patient wishes to undergo a forensic examination, providers must obtain written informed consent for the examination and forensic evaluation prior to the history and physical. Obtaining consent carries important psychological implications after a sexual assault in which a victim’s consent right was violated. Forms that require information about gender or sex should allow victims to write a response that may not be listed as an option. Sexual assault examination teams should be involved as early as possible if available. Many institutions in the United States arrange to utilize sexual assault nurse examiner (SANE) programs, which provide highly specialized treatment for sexual assault victims.[4]

The history must be taken in a private room using a compassionate tone. In patients who do not wish to complete a forensic examination, providers should take an appropriately tailored history rather than an exhaustive account of the details of the encounter. An appropriate history includes information necessary for medical treatment such as past medical history, gynecologic history, symptoms since the assault, and details of the assault. Recounting the details of a sexual assault may re-traumatize victims, so the need for assault details should be balanced with sensitivity to the patient’s emotional needs. However, it may be necessary to determine if the patient is at risk for sexually transmitted infections, pregnancy, or further neurologic examination in cases of loss of consciousness. In addition to the standard gynecological history, if a patient uses an oral contraceptive, providers should ask about missed doses. This information will assist in deciding the administration of post-coital contractive medical treatment.

In patients requesting a forensic examination, they will complete a narrative history as well as a "checkbox history." The narrative history will be the patient's recount in their own words what occurred during the sexual assault. The checkbox history is typically a list of questions with yes or no responses. Historical assault information may be important when trying to correlate physical findings or corroborating evidence. However, due to assault-induced distress and/or drug-facilitated sexual assault, victims commonly cannot answer all the questions. It is perfectly acceptable to use the “unknown” response when completing legal forms. These questions go further into detail on the sexual assault discussing specific details, activities after the assault, and date of last sexual intercourse. Again, these questions may re-traumatize the patient, so they should be balanced with sensitivity to the patient's emotional needs.  [5]

Before beginning the physical examination, remind a patient that he, she, or they are in control of every element of the examination and may refuse at any point. Physical examination goals include the determination of medical treatment needs. The physical exam should be tailored to the patient's needs based on their medical history if they are not undergoing a forensic examination. To collect debris as a part of the forensic examination, patients should undress over a clean sheet or paper, dropping the clothes if collecting them for evidence. Providers should perform a complete skin exam, noting any traumatic findings including but not limited to lacerations, abrasions, bruises, swelling, and bite marks. Make notations regarding areas that are tender as bruising may develop later and may be difficult to identify in patients with more pigmented skin. Examiners should note, photograph, and collect any debris, wet secretions, and crusted areas of dry secretions observed on the skin. Part of most sexual assault includes an oral exam for injury making sure to look at both the buccal and gingival mucosa in addition to the usual medical, oral exam.[6]

Most sexual assaults involve non-consensual genital contact hence providers need to examine the patient’s external genitalia for abrasions, lacerations, bruises, bleeding, areas of tenderness, and wet or dry secretions. Providers should perform a speculum exam in victims with vaginas to look for injuries to the vaginal wall, cervix, or any foreign bodies if a patient can tolerate such an exam and has reported genital contact or was unconscious. Examiners will collect specimens from the external genitalia, vaginal vault, and cervix as described later in evidence collection. A bimanual examination is not a routine part of the sexual assault examination. The penis and scrotum should be examined for injury, in appropriate patients.[7] Inspect the anal and peri-anal area for injury, swelling, and bleeding in all gender victims and perform anoscopy if the patient reports anal penetration, anal pain, anal bleeding, or has reported a loss of consciousness during the assault. Patients may display anal injuries during anoscopy even with a normal external anal exam and no complaints of pain. Anal and/or rectal swabs forensic collection should be done during anoscopy.[8]

If the patient is completing a forensic examination, there are additional goals of specimen collection for crime lab analysis, and documentation of injury findings. In an evidence collection kit, there will be a set of directions for the provider to follow. The forensic examination sample collection of the patient's blood, oral swabs, fingernail scrapings, clothing collection, hair combings (head and pubic), external and internal genital swabs, perianal swabs. The patient should be reminded that they have the right to refuse any part of the examination at any time. Swabs are employed to collect liquid evidence from the patient and are collected in sets of twos. One swab will go to lab testing, and the other is held for the defense to have if the case goes to trial. Dry swabs are used to collect wet specimens. Swabs wetted with sterile water are used to collect dry specimens. Swabs are allowed to airdry and placed in a paper envelope to prevent mold growth on wet specimens. 

Documentation of injuries discovered on the physical exam should describe the body or genital location, bleeding, size, and color. Photography provides excellent documentation and is standard procedure for sexual assault examinations performed by sexual assault forensic examiners (SAFEs) or sexual assault nurse examiners (SANEs). A SAFE often uses toluidine blue dye to highlight injury when taking photographs. Additionally, a SAFE employs a method to enhance the identification of an injury, such as a macro lens on a digital camera or a free arm medical magnifier. Gentle separation of the labia and inferior traction may increase the examiner's ability to detect injuries to the perineum and hymen. [7]

Issues of Concern

Informed consent in sexual assault examinations is an ethical dilemma for several vulnerable populations that are unable to consent to the examination. In the pediatric population, young children may not have the capacity to discuss what occurred or to consent to a forensic examination. Additionally, it may be difficult for young children to comply with a physical examination that causes them pain or discomfort.[9]  As a child in the US is sexually assaulted every nine minutes, it is an issue that will arise in providers dealing with sexual assault. A positive pregnancy test, the presence of a sexually transmitted infection like gonorrhea or chlamydia, or the presence of sperm may be enough to prove sexual assault in a minor. [10] Sexual assault in a minor should be reported to child protective services. Patients with cognitive impairments or dementia may also be unable to consent to a physical or forensic examination and have similar issues as the pediatric population. Sexual assault of an elder or cognitively impaired adult should be reported to adult protective services.

Care for patients should be inclusive and tailored to support patients of all gender identities and sexual orientations. The US Department of Justice reports that rates of sexual assault are higher for LGBT individuals. There are too few guidelines on the delivery of gender-sensitive care in sexual assault health services considering these patients are experiencing a higher rate of sexual assault. One study suggests that the lack of an integrated and equitable approach to sexual assault examinations limits these patients' access to the standard of care. [11]

Clinical Significance

According to 2019 data collected by the US Department of Justice, sexual assault occurs every 73 seconds in the United States and every nine minutes for pediatric victims. The lifetime rates of sexual assault are between 17 to 18% for women and 3% for men. These numbers are likely under-estimations of the true values and do not account for rates of LGBT sexual assaults, for which the rates are higher. This demonstrates that sexual assault has a clinically significant impact on patients of which physicians, nurses, and other healthcare practitioners need to be cognizant, especially in the documentation and forensic examination of these patients.  [12]

Sexual assault may trigger severe depression and even suicidality. The practitioner’s history includes assessment for suicidality and, if found, immediate referral to a mental health professional. In most areas in the United States, rape crisis advocates can provide timely support to victims during the examination and throughout follow-up. Psychological and advocacy follow-up programs must be arranged. Survivors may suffer from rape trauma syndrome, which presents with a pattern of symptoms that are similar to posttraumatic stress disorder. The patients must plan to follow up approximately 1 to 2 weeks after the initial evaluation to determine the need for further counseling.[13]

The way a provider interacts with victims can make a difference in their ability to begin the path of recovery and healing.  The clinical significance of a kind and compassionate patient-centered encounter is that of improved physical and mental well-being during and after the encounter. Providers should keep this goal in mind throughout history taking and physical examination.[14]

Enhancing Healthcare Team Outcomes

Some hospitals have Sexual Assault Nurse Examiner (SANE) programs in place where a specially trained nurse completes the forensic examination. While another provider may perform the screening exam for life-threatening conditions and other injuries, the forensic evidence collection is of the sexual assault nurse examiner. Initial evidence for SANE programs has suggested improved outcomes in patient psychological recovery, treatment, evidence collection, and prosecution of cases. [15]  A review comparing the historical control of no SANE practitioner to SANE practitioners in pediatric emergency departments found that there was improved quality of care found in cases managed by pediatric SANEs. This improvement included testing for STIs, documentation of injury, and assessment of pregnancy.[16] (Level 4).